Online Enquiry Form

Where are you currently located?*

Perth
Regional WA
Other

Please state city/town where you currently are*

Please provide the following information

Your full name*

Gender

Male
Female

Date of birth

Do you have a partner accompanying you?

Yes
No

If yes, please provide name

Your partners date of birth

Do you have children in your care?

Yes
No

If yes please provide the full names and ages of the children in your care*

Is there anybody else with you?

Yes
No

If yes please provide the full names and ages of the people with you*

Contact phone numbers/details*

Can we call you on these numbers?

Yes
No

Is there are best day and time to call you during the hours our service is open?

Yes
No

Date*

Time*

:

Email address

Enter Email Confirm Email

What is your current accommodation situation?

Staying with family or friends
Facing eviction
Hospital
Sleeping rough in a public place
Crisis / Emergency Accommodation

Are you currently homeless?

Yes
No

Where did you sleep last night? Please state location*

Can you sleep there again tonight?*

Yes
No
Unsure

How long can you keep staying in this location?*

Are you at risk of homelessness?

Yes
No

If yes, what is the risk?*

Are there any current legal issues affecting you or your family/tenancy? (e.g. Violence Restraining Orders, tenancy breaches, custody disputes, facing legal charges, on parole, etc)

Yes
No

If yes, please identify*

Are you currently receiving any support from other agencies?

Yes
No

If yes, what agencies?

If yes, please state where you have come from?

Have you or anyone with you recently been tested for COVID-19 and/or waiting for results?

Yes
No

If yes, when?*